Telehealth: a tool for the 21st century (PPT)
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Telehealth: a tool for the 21st century (PPT)

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  • 1. Telehealth: A tool for the 21 st century Karen S. Rheuban MD Professor of Pediatrics Medical Director, Telemedicine University of Virginia
  • 2. Disclosure
    • I have no financial relationships to report that would create any conflict of interest in relationship to this presentation
  • 3. Objectives
    • Understand the applications of telemedicine in the delivery of healthcare, especially as they relate to children
    • Understand statutory and regulatory issues impacting the development of telemedicine networks
  • 4. Definitions
    • “ Telemedicine” is the use of medical information exchanged from one site to another via electronic communications to support
          • Medical diagnosis
          • Ongoing patient care
          • Remote patient monitoring
      • “ Telehealth” encompasses a broader definition of remote healthcare that does not always involve clinical services
          • Health-related distance learning
  • 5. Telemedicine: History
    • Alexander Graham Bell
    • Hugo Gernsback (vision)
    • Massachusetts General
    • U of Nebraska
    • NASA
    • Dept of Defense
    • University of Virginia
  • 6. Mission
    • Facilitate the Health System’s missions of
            • Clinical Care
            • Teaching
            • Research
            • Public Service
  • 7. Services
    • Videoconferencing for patient care
    • Store and forward applications
    • Distance learning
            • health professionals
            • patients
            • students
  • 8. UVA Specialty/Subspecialty Participants
    • Cardiology
    • Dermatology
    • Diabetes
    • Emergency Medicine
    • Endocrine
    • ENT
    • Gastroenterology
    • Genetics
    • Geriatrics
    • Gynecology
    • Hematology
    • Infectious Disease
    • Nephrology
    • Neurology
    • Neurosurgery
    • Ophthalmology
    • Orthopedics
    Obesity Oncology/Tumor boards Pain management Pediatric cardiology Pediatric nephrology Pediatric oncology Plastic surgery Psychiatry Pulmonary medicine Radiology Rheumatology Surgery TCV Toxicology/Poison control Urology Wound care
  • 9. Partnerships
    • Academic-community hospital linkages
    • Academic-academic hospital linkages
    • Rural clinics (FQHCs, Veteran’s clinics)
    • Virginia Department of Health
    • Virginia Department of Corrections
    • School health
    • Nursing home
    • Home telehealth
  • 10. Barriers to Access
    • Geographic
      • >20% of US population reside in rural areas
      • Burden of transportation to care generally borne by patients
      • Medicaid programs bear the burden of transportation costs
        • 1999: >$50 million/year in Virginia alone
      • Multiple definitions of rural
    • Financial
      • The uninsured, underinsured (> 40 million uninsured)
      • Delayed access to services for uninsured
      • High cost of travel for locally unavailable specialty care
  • 11. Barriers to Access
    • Societal
      • Societal stigmatization
      • Cultural barriers
      • Language barriers
    • Maldistribution/shortage of providers
      • Predicted shortage of physicians 85,000-200,000 by 2020
      • Urban predominance of specialty providers
      • Isolation of rural health providers
      • Need for continuing health professional education
  • 12. Benefits of telehealth
    • Patients :
      • Timely access to locally unavailable services
      • Spared burden and cost of transportation
      • Improvement in quality of care
    • Health professionals
      • Access to consultative services
      • Access to CME
      • Primary care oversight of patient care
    • Rural communities
      • Enhanced healthcare/economic empowerment
  • 13.  
  • 14.  
  • 15. Patients served: UVA program
    • >15,000 patient encounters
    • >30,000 teleradiology readings
    • Services in >30 different specialties
      • Emergency
      • Urgent
      • Single consults
      • Block scheduled clinics
      • Screenings with store forward technologies
        • New mobile digital mammography van
        • Retinopathy
  • 16. More than technology and numbers: Saving lives: Infant with Interrupted aortic arch
  • 17. More than technology and numbers: Facilitating expert care
  • 18. Enhancing access
  • 19. Educational programs
    • Broadcast continuing health professional education
    • UME, GME
    • Patient education
    • School Health Projects
  • 20. International humanitarian outreach Swinfen Charitable Trust
    • In conjunction with the Center for Online Health in Brisbane
    • Automated email consultation system
    • Physician to physician consults with attached digital images
    • Volunteer consultants in 59 subspecialties, 1479 cases
    • Consults from:
  • 21. Pre/perinatal care ANGELS program - Arkansas
    • Antenatal Neonatal Guidelines, Education and Learning System
      • University of Arkansas/Medicaid partnership
      • Increase prenatal screening and referrals
      • Genetic counseling, targeted ultrasounds, MFM consultations, pediatric consultations
      • Outcomes
        • 2 year period – 467 congenital malformations
        • 50% referred for delivery
        • No-show rate for TM clinics 12%, UAMS 20%
        • Shannon Barringer, UAMS – Presentation Pediatric Telehealth Colloquium, 9/07
  • 22. Tele-ophthalmology
    • Tele-ophthalmology technologies: live or store forward
      • Most data in patients with diabetes
      • Retinopathy of prematurity
    • ATA: Tele-ophthalmology standards
  • 23. Pediatric cardiology
    • Incidence of CHD is 8/1000 live births
    • Traditional models of care:
      • Schedule appointment
      • Emergency transfer
      • Wait for field clinic
      • Obtain echo and mail, courier
    • Models for tele-echocardiography
      • Live interactive support of remotely located technologists
      • Store forward images sent in digital format
  • 24. Acute stroke intervention
    • Challenge of lack of access to stroke neurologist in rural areas
    • Time is of the essence (3 hour window for thrombolytic agents
    • Increase use of TPA in rural hospitals from 4% to 23%
  • 25. HIV/AIDS
      • Outcomes: UVA Telehealth HIV Program 1
        • 213 correctional patients treated with 1812 visits over 5 year period
        • Of patients naïve to therapy:
          • 77% attained undetectable viral load (<50 copies/ml)
          • 50-60% in HIV clinic
          • 40% receiving community based care by non-HIV specialists
      • 1 Rheuban,KS, Wispelwey B et al HIV/AIDS, HRSA Telemedicine Technical Assistance Documents 2004
  • 26. Cancer outreach: Mobile digital mammography
  • 27. Tele-pathology
    • Primary interpretation
    • Second opinion
    • Collaborative tumor boards
    • Remote access to clinical trials
  • 28. Tele-mental health
    • Shortage of mental health providers in rural areas
    • Consultations, medication management
    • Sign language for hearing impaired
    • Interpreter services
  • 29. Tele-mental health
    • Comprehensive review of the medical literature in telepsychiatry 1
      • Technology predominantly interactive videoconferencing
      • Improve access, shorter wait times
      • High rates of patient satisfaction in all age groups
      • Diagnosis change from PC provider diagnosis in 91%
      • Medication changes in 57%
      • Reduced geriatric hospital admissions from long-term care facility by 59%
      • 1 Hilty, D, et al, Can J Psych 2004; 49:12-23
  • 30. e-ICU
    • Models for support of intensive care units 1
      • Two adult ICUs in large tertiary care hospital system
      • 2140 patients receiving ICU care
      • E-ICU services from 12 noon – 7am
      • Program utilized off-site intensivists, physician extenders, electronic data display, decision support tools
      • Results:
      • Hospital mortality decreased from 12.9-9.4%
      • ICU length of stay shorter 4.35-3.63 days
      • 1 Breslow, MJ, Crit Care Med 2004 32(1): 31-38
  • 31. Remote monitoring and Home telehealth
          • Remote monitoring
            • CHF
            • Diabetes
            • COPD/ Asthma
  • 32. Challenges
    • Funding of telehealth (Stark, Anti-kickback Laws)
    • Reimbursement
    • Outcomes
    • Confidentiality
    • JCAHO
    • Licensure
    • Malpractice
    • Telecommunications venue/costs
    • Integration with EMRS/RHIOS
    • Interagency alignment related to policies
      • Federal (definition of rural, rural vs urban)
      • State (eligible plans, coverage of store and forward)
  • 33. Outcomes:2006 Agency for Healthcare Research and Quality (AHRQ)
      • Still significant gaps in the evidence base between where telemedicine is used and where its use is supported by high-quality evidence.
      • Further well-designed and targeted research that provides high-quality data will provide a strong contribution to understanding how best to deploy technological resources in health care.
    Hersh, W, Supplement. Telemedicine for the Medicare Population: AHRQ Evidence Report/Technology Assessment Number 24, Supplement, 2006
  • 34. Virginia Telehealth Network
    • Multi-institution/organization collaboration initiated by Virginia Department of Health
    • Inventory current activities
    • Increase awareness of telehealth
    • Increase collaboration
    • Secure funding – competitive grants, appropriations
    • Advocate in support of critical policy issues
  • 35. The future of telehealth
    • Outcomes
    • Standards
    • Demonstration projects (ARRA)
    • Integration into mainstream medicine
    • Collaboration amongst providers, policymakers, regulators
    • Champions at all levels
    • Engage your legislators!!!
  • 36. Champions Congressman Rick Boucher, Mrs. Lisa Hubbard, Alexandra Bartley
  • 37.